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Surgical Management of Secondary Tricuspid Valve Regurgitation: Anulus, Commissure, or Leaflet Procedure?
Jose L. Navia, Edward R. Nowicki, Eugene H. Blackstone, Daniel E. Nento, Jeevanantham Rajeswaran, A. Marc Gillinov, Lars G. Svensson, Sharif Al-Ruzzeh, Bruce W. Lytle; Cleveland Clinic, Cleveland, OH
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Objective: Anuloplasty has been the main technique used to manage tricuspid valve (TV) regurgitation (TR) accompanying left-sided heart valve disease, but techniques at the commissure or leaflet level may also be useful. This study sought to compare early and long-term success of procedures performed at anular, commissural, leaflet, and combined levels.
Methods: From 1990 to 2008, 2,277 patients underwent TV procedures for secondary TR concomitantly with mitral (n=1,527, 67%), aortic (n=180, 8.0%), or combined (n=570, 25%) valve surgery. These included anulus (rigid prosthesis [n=584, 26%], flexible prosthesis [n=1,052, 46%], DeVega suture [129, 5.7%], and Peri-Guard [n=185, 8.1%] anuloplasty), commissure (Kay [n=248, 11%]), and leaflet (edge-to-edge suture [n=79, 3.5%]) procedures. 4,745 postoperative transthoracic echocardiograms in 1,965 patients were analyzed (median follow-up 20 days) and TV reoperations identified at follow-up (median 1.2 years).
Results: At 3 months, prevalence of 3+/4+ TR was least for combined Kay and leaflet procedures (2.4%) and Peri-Guard anuloplasty (3.8%), and similar (8.7% to 11%) for other procedures (Figure). However, by 5 years, 3+/4+ TR had increased only slightly to 12% for isolated rigid prothesis anuloplasty. It was progressively greater for all other anular procedures (flexible prosthesis [16%], DeVega [24%], and Peri-Guard [44%]), and 19% for the Kay procedure. Freedom from TV reoperation was 98% at 5 years, similar for all procedures (P=.3).
Conclusion: Early success of treatment for TR secondary to left-sided heart valve disease is best sustained over time by rigid prosthesis anuloplasty alone. The protracted failure pattern after Peri-Guard anuloplasty suggests abandoning this procedure.

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